00-form_pendaftaranujianpkl.docx

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KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI UNIVERSITAS BRAWIJAYA PROGRAM KEDOKTERAN HEWAN Jalan Mayjen Haryono No : 169 Malang 65145 Telp. +62341- 573642, Fax. +62341- 573642, 551611 psw 362 http://www.pkh.ub.ac.id email : [email protected] Form Pendaftaran Ujian PKL NIM : ...................................................... ........ Nama MHS : .............................................................. Judul : ...................................................... ...................................................... ...................................................................... .................................................................... ...................................................................... .................................................................... Instansi PKL : ...................................................................... ..................................... Yang Akan Diselengggarakan Pada : Hari : ……………………………………….. Tanggal : ……………………………………….. Pukul : ……………………………………….. Tempat Ujian : ………………………………………..

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Page 1: 00-Form_PendaftaranUjianPKL.docx

KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGIUNIVERSITAS BRAWIJAYA

PROGRAM KEDOKTERAN HEWANJalan Mayjen Haryono No : 169 Malang 65145

Telp. +62341- 573642, Fax. +62341- 573642, 551611 psw 362http://www.pkh.ub.ac.id email : [email protected]

Form Pendaftaran Ujian PKL

NIM : ..............................................................

Nama MHS : ..............................................................

Judul : ............................................................................................................

..........................................................................................................................................

..........................................................................................................................................

Instansi PKL : ...........................................................................................................

Yang Akan Diselengggarakan Pada :

Hari : ………………………………………..

Tanggal : ………………………………………..

Pukul : ………………………………………..

Tempat Ujian : ………………………………………..

Nama Tim PengujiTanda

Tangan

Pembimbing 1 :

NIP.

Pembimbing 2 :

NIP.

Penguji :

NIP.

Mengetahui Malang, .....................................Wakil Bidang Akademik

Prof.Dr.Aulanni'am,drh.,DES NIP. 19600903 198802 2 001